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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON-AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (Complete in Triplicate) fl Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin .[Local Health District. Job Address 7,2 f W• City ILit Lot Siz� xlo PM Owner's Name Address . Phone 93 1 " (03 10, Contra cto 1 i Address Q�� gxb1 �G�Cr License IVo. 3?g z ZP Phone (07 7 S"fo S" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -""'""- TYPE OF WELL-- PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing' Speci#ications- ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal--_ _ __ Type of Grout ----• .S ❑ Irrigation..,.,., ---Approx. Depth ❑ Eastern - Surface Seal Installed byi Repair Work Done 71 pe of Pump H.P. State Work;pone Well Destruction ❑ - Well Diameter Sealing Material (top 50.1. "Depth ~"' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1j` available within 200 feet.) T Installation will serve: Residence A--"Commercial w Other Number of living units: Number of bedroqms _ I Y Character of soil to a depth.of 3 feet: Water table depth. SEPTIC TANK,°- +�f., .� Type yp 9 Caacit p y No. Compartments I'dC�0 PKG. TREATMENT PLT. ❑. c.r Method of Disposal ! Distance to nearest:- 'Well AGO Foundation 1-D Property Line SO LEACHING LINE 66--N.. & Length of lines : Total length/size q0 X oZ FILTER BED ❑ Distance to nearest: Well - /00 Foundation /O Property Line ... 4 SEEPAGE PITS ❑ Depth Size = 14 Number "�J i SUMPS ❑ Distance to nearest: Well Foundation t ""'Property une DISPOSAL PONDS ❑ s I hereby-certify that 1 have prepared this application and-that the work will be done in accordance with San Jo3Aquin couritV ordinance's;-stafe laws;and— j rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican st call for a req 'red inspections. Complete drawing on reverse side. 9 Q Signed Title: V I '`- ' Date: 1 U M FOR DEP TMENT USE.,ONLY 1"t- Application Accepted by 11 Dater Area Pit or Grout Inspection by Date Fin Inspection by Date Additional Comments: - T❑Stk_466-6761 , ❑ Lodi 369-3621 ❑ Manteca SZ0104 `'❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-`NO. r ) + EH13-24(REV.1/95) 't EH 1426 � C?0 7/ r i